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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_917_Библиотеки_им_академика_М_И_Перельмана.pdf
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Fig. 21.1 Fecal peritonitis
D. A. Kleiman and S. A. Lee-Kong
hernia formation, injury to adjacent organs, anastomotic complications, and risks
associated with general anesthesia. In fact, up to 45% of patients who undergo a
Hartmann’s procedure are never reversed, oftentimes due to fear of these complications or other signicant comorbid conditions which can complicate an otherwise
elective operation [4, 5].
The morbidity associated with a traditional open Hartmann’s reversal has led
many surgeons to explore minimally invasive options. However, there are signicant inherent challenges to this approach, generally related to the fact that the initial
surgery may have been performed via an open approach. These patients may present
with signicant intra-abdominal contamination, resulting in dense intra-abdominal
adhesions. Patients’ comorbid conditions may also make a minimally invasive
approach challenging. However, in well-selected patients, a minimally invasive
approach can be performed safely with low perioperative morbidity and may help
increase stoma reversal rates.
In this chapter, we will discuss indications and contraindications of minimally
invasive Hartmann’s reversal and key aspects of preoperative evaluation and
describe general steps of a minimally invasive technique.
Indications andContraindications
A minimally invasive Hartmann’s reversal may be considered in any patient undergoing the procedure. Ideal candidates are those whose initial operation was performed through either a limited laparotomy incision (i.e., a lower midline below the
umbilicus) (Fig.21.2) or a hybrid laparoscopic/open resection (i.e., laparoscopic
hand-assisted via Pfannenstiel incision), although any patient considered suitable
for laparoscopy may be a candidate [6].
While there are no absolute contraindications to minimally invasive Hartmann’s
reversal, two factors that are most likely to limit the successful completion of a
minimally invasive approach are intra-abdominal adhesions and patient comorbidity. Obesity has been identied as an independent risk factor for complications in
patients undergoing Hartmann’s reversal [7]. Patients with a BMI≥30kg/m2 are at
increased risk of morbidity, surgical site infection, and need for diverting ileostomy
21 Laparoscopic andRobotic Hartmann’s Reversal: Strategies toAvoid Complications
Fig. 21.2 Straightforward
abdominal access
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creation. While minimally invasive surgery may help ameliorate some of these
risks, the technical challenges faced in obese patients can still make minimally invasive Hartmann’s reversal difcult. Surgeons often recommend obese patients to lose
weight prior to elective surgery. However, many patients nd this difcult.
Consultation with a dietician, weight loss specialist, or bariatric surgery program
should be considered preoperatively.
Patients who suffered medial sigmoid perforations resulting in a large amount of
purulent or feculent peritonitis at the index operation are more likely to have extensive lower abdominal or pelvic adhesions, making a minimally invasive approach
challenging. Similarly, patients with long midline laparotomy incisions extending
well above and below the umbilicus may have limited domain for safe laparoscopic
entry into the abdomen (Fig.21.3). Patients who have had multiple open surgeries
in the past may experience difculties with safe laparoscopic abdominal entry.
Laparoscopic Hartmann’s reversal can require extended periods of time in steep
Trendelenburg position, particularly if extensive pelvic dissection is required.
Patients with signicant congestive heart failure, chronic obstructive pulmonary
disease, and morbid obesity may not be able to tolerate this positioning, precluding
a minimally invasive approach.
318
Fig. 21.3 Difcult
abdominal access
D. A. Kleiman and S. A. Lee-Kong
Principles andQuality Benchmarks
The key steps to a successful minimally invasive Hartmann’s reversal include the
following:
1. Safe laparoscopic lysis of intra-abdominal adhesions
2. Takedown of the colostomy without injuring the colon
3. Sufcient mobilization of the splenic exure and descending colon (often
needed)
4. Identication, mobilization, and preparation of the rectal stump for creation of
the anastomosis
5. Performance of a tension-free colorectal anastomosis.
Preoperative Planning, Patient Workup, andOptimization
(Box 21.1)
Most Hartmann’s procedures are performed emergently with little or no preoperative planning. In contrast, a Hartmann’s reversal is an elective procedure. Careful
and thoughtful preoperative assessment and planning is essential. Often, this is an
excellent opportunity to complete aspects of the preoperative workup that ideally
Box 21.1 Preoperative Checklist Prior to Hartmann’s Reversal
[ ] Review operative report
[ ] Review pathology
[ ] Colonoscopy
[ ] Water-soluble enema of rectal stump
[ ] Physical exam (assess sphincter function)
[ ] Medical/cardiac clearance
[ ] Ureteral stents
21 Laparoscopic andRobotic Hartmann’s Reversal: Strategies toAvoid Complications
would have been performed prior to the original sigmoid colectomy. For example,
recent colonoscopy reports should be reviewed. If one was not recently performed,
this should be considered. Thorough cardiopulmonary assessments should be performed as part of the preoperative workup.
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Review Operative Report
Whenever possible, the original operative report of the Hartmann’s procedure should be
carefully reviewed. Details such as the degree of abdominal contamination, bleeding,
and any pre-existing adhesive disease may predict how hostile the abdomen will be during colostomy closure. It is also important to note where the distal margin of resection is
and which, in any, major mesenteric vessels were ligated. Additional information such
as whether suture tags were left on the end of rectal stump may also be helpful.
Review Pathology Report
The pathology report from the original surgery should be reviewed to ensure that
there was no incidental cancer diagnosis or evidence of inammatory bowel disease
at the original operation.
Colonoscopy (Colon andRectal Stump)
If the patient has not had a recent colonoscopy, this should be performed prior to
Hartmann’s closure. This should include evaluation of the remaining colon through
the colostomy as well as the rectal stump. If the patient is up to date with colonoscopy (i.e., within the past year), then at a minimum a exible sigmoidoscopy of the
rectal stump should be performed to assess the health of the stump and to ensure that
it is not structured or obstructed by inspissated mucus or stool. For patients in whom
the indication for Hartmann’s procedure was colorectal cancer, endoscopy should
be performed to rule out persistent or recurrent cancer in the rectal stump. The
length of the rectal stump is important to know prior to attempt at colostomy closure, as a short stump may impart poorer functional outcomes after closure.
Distensibility of the rectum, which may be poor due to a brosing pelvic process
from sepsis, may also portend poorer functional outcomes.
A water-soluble contrast enema of the rectal stump is also helpful to ensure that
the staple line at the top of the stump is intact and that there are no sinus tracts to
adjacent organs.
Assessment ofSphincter Function
A detailed history can reveal if the patient had any degree of fecal incontinence prior
to them developing perforated diverticulitis. A digital rectal exam should be performed to assess the patient’s sphincter function prior to Hartmann’s reversal. If the
320
patient has poor sphincter function, then he or she should be counseled on the
expected functional outcomes of reversal, and the option of keeping a permanent
colostomy should be discussed. Anorectal manometry may also be considered,
although not necessary, if there are any concerns about sphincter function. Patients
with long-standing fecal diversion may have impaired function, and this should be
clearly discussed with the patient prior to attempts at reversal.
D. A. Kleiman and S. A. Lee-Kong
Cross-Sectional Imaging
Although not essential, review of any available cross-sectional imaging (prior to or
after the original sigmoid colectomy) should be performed. This may help dene
relevant anatomy, as well as identify potential anatomic issues that may arise at the
time of colostomy reversal. For example, large uterine broids may limit access to
the pelvis for rectal dissection and anastomosis. Tracing the course of the ureters
may also be possible, allowing for anticipation of potential areas of injury during
the surgery. This may also reveal parastomal and/or midline hernias that can be
addressed simultaneously with the takedown operation.
Ureteral Stents
Bilateral ureteral stents should be considered to assist with intraoperative identication of the ureters and help ensure that they are protected. Patients with Hinchey III
or IV diverticulitis often have dense brosis in the lower abdomen and pelvis, making intraoperative identication of the ureters challenging.
Operative Setup
A variety of minimally invasive and hybrid techniques are possible based on equipment availability and surgeon preference. As for all colorectal surgery procedures,
straight laparoscopic, single-incision laparoscopic, laparoscopic hand-assisted, and
robotic-assisted techniques have all been described. There is no single approach that
will work for everyone, so the surgeon should remain adaptable and able to alter the
surgical approach based on the intraoperative ndings.
Regardless of which minimally invasive technique is chosen, there are a few
common themes in preparing for the procedure. The patient should be positioned on
the operating table with access to the anus to allow for passage of a transanal stapling device or intraoperative endoscopy. Our preference is supine on a split-leg
table, but modied lithotomy position is also acceptable (Figs.21.4 and 21.5). Both
arms should be tucked, if possible, to allow both the surgeon and the rst assistant
to stand cephalad on either side of the patient facing toward the pelvis. The patient
should lie on a nonskid mat (our preference is either a bean bag or foam mat), and a
shoulder strap should be utilized to secure the patient to the operating table to prevent sliding with steep positioning.
21 Laparoscopic andRobotic Hartmann’s Reversal: Strategies toAvoid Complications
Fig. 21.4 Lithotomy position
321
Fig. 21.5 Split-leg
position
322
D. A. Kleiman and S. A. Lee-Kong
Robotic-assisted Hartmann’s reversal should be reserved for surgeons both
trained and comfortable using currently available robotic platforms. The DaVinci
Si® or Xi® platforms (Intuitive Surgical, Sunnyvale, CA, USA) are the most widely
available. Port placement strategies in general follow conventions unique for each
platform. For the DaVinci Si, placing the cannulae in the right abdomen at least
8cm apart in a “C” conguration is most helpful. One can take down the end colostomy at the beginning of the procedure, or once it is determined intraoperatively,
that safe colostomy reversal is possible. For the DaVinci Xi system, the authors nd
it helpful to place the cannulae in a nearly straight vertical line along the right abdomen. The arm docked closest to the pelvis should be able to accommodate an endoscopic stapler, should division of the rectal stump be necessary. The Xi platform has
the added advantage of intraoperative table motion, which can aid in operating in
more than one abdominal quadrant comfortably (Fig.21.6).
For both Si and Xi platforms, intra-abdominal adhesions are typically assessed and
managed laparoscopically before the robot is docked. Availability of laparoscopic
scissors with monopolar energy is helpful during this portion of the procedure and
adds minimal additional cost to the case. Once the robotic trocars are safely inserted,
the patient is positioned in steep Trendelenburg position with right side down. The
small bowel and omentum are lifted out of the pelvis into the right upper quadrant.
Fig. 21.6 Xi robotic port
placement
21 Laparoscopic andRobotic Hartmann’s Reversal: Strategies toAvoid Complications
323
The authors nd it helpful to do this laparoscopically prior to docking the robot. The
table is then lowered as low as it can go, and the robot is docked from the patient’s left
side. If “targeting” is used on the Xi platform to help align the robotic arms, the
authors prefer to target the left pelvic inlet, as this typically allows for comfortable
reach from the splenic exure to the pelvis. If the colon proximal to the splenic exure
requires mobilization, the surgeon should be prepared to undock and re-dock as necessary. This can be easily accomplished with the Xi by simply rotating the boom and
retargeting. However, with the Si platform, the patient cart may need to be moved to
the patient’s right side. This can be quite burdensome and is often an indication for
conversion to a laparoscopic or open approach. The bedside assistant is positioned on
the patient’s right side. A sitting stool is provided so that the assistant can comfortably
access the ports while staying below the level of the moving robotic arms.
Single-incision laparoscopic surgery (SILS)-assisted Hartmann’s reversal can
also be considered, if the surgeon is appropriately trained and comfortable. Those
who perform SILS procedures often gain abdominal access by rst taking down
the end colostomy and placing the SILS port at this location. Proponents advocating for this technique report the advantage of avoiding the adhesions often present
in the midline from prior laparotomy. The use of an angled or exible-tip laparoscope can be very helpful to overcome the difculty encountered with the use of
straight laparoscopic instruments and their close proximity. As the vast majority of
surgeons do not perform SILS procedures, there are no reliable data examining
SILS Hartmann’s reversal.
Operative Technique: Surgical Steps
There are many nuances of technique that will vary depending on surgeon preference and the minimally invasive approach that is selected. Here, we will describe
the general steps of any minimally invasive Hartmann’s resection. These basic steps
can be performed using any minimally invasive technique.
The rst challenge is to safely gain entry into the peritoneal cavity and establish
pneumoperitoneum. This can be quite challenging depending on the degree of
intra- abdominal adhesions and is a common reason for early conversion. In general, we allow the patients’ previous incision to guide our site of abdominal entry.
We try to avoid entering the abdomen directly through a previous incision, as one
is likely to encounter dense adhesions immediately underneath. If the patient has a
lower midline or Pfannenstiel scar, then a supraumbilical direct cutdown (“Hasson”)
technique is a good option. If their scar extends above and below the umbilicus,
then an off-midline entry site may be better suited. For off-midline entry, our preference is to use a Veress needle in the left upper quadrant at Palmer’s point (two
ngers below the costal margin at the genu of the rib) (Fig.21.7). Once pneumoperitoneum has been achieved, a 5mm laparoscopic camera is advanced through
the abdominal wall inside a clear 5mm trocar so that the surgeon can observe each
layer of the abdominal wall as the trocar passes through it until the abdominal
cavity is safely entered.
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Fig. 21.7 Veress needle
entry
D. A. Kleiman and S. A. Lee-Kong
Oftentimes, taking down the colostomy with early placement of the anvil into the
proximal colon may be the safest and “fastest” approach for entering the abdomen.
A balloon trocar or a wound protector with a cap can be subsequently placed. This
is an ideal strategy for those who prefer a single-incision laparoscopic approach,
whereby the same incision is used for specimen extraction.
Once pneumoperitoneum is established and the rst trocar has been placed, we
rst assess for visceral organ injury due to port placement. Next, a quick survey of
the abdominal cavity is performed to assess the burden of the adhesive disease and
make a decision as to whether the procedure can safely be performed with minimally invasive techniques. If yes, then additional trocars should be placed.
We then proceed with complete laparoscopic adhesiolysis. This can be quite
tedious depending on the density of adhesions. Often patients who have had severe
peritonitis from the inciting diverticular process will form difcult to manage adhesive disease. We nd that delaying Hartmann’s reversal for 3 to 6months allows for
improvement in the adhesive burden and may help facilitate a minimally invasive
approach. The surgeon needs to remain patient and exible and may need to alter
their usual trocar placement in order to handle the pattern of adhesions that are
encountered. The rectal stump is then mobilized and inspected. Once we conrm
that the rectal stump is suitable for creation of a colorectal anastomosis, we then
21 Laparoscopic andRobotic Hartmann’s Reversal: Strategies toAvoid Complications
Fig. 21.8 Medial to
lateral mobilization of
splenic exure
325
proceed with taking down the colostomy. Great care is taken not to damage the
colon within the abdominal wall so that it can be used for creation of the anastomosis. The mucocutaneous junction will need to be trimmed from the colostomybearing segment prior to use in creating the anastomosis. The anvil of an end-to-end
circular stapler is then secured in place to the end of the descending colon with a
purse-string suture. The colon is then delivered back into the abdomen, and pneumoperitoneum is reestablished. A small wound protector can be placed through the
colostomy site and then sealed with a cap or by twisting it in order to reestablish
pneumoperitoneum. Alternatively, if a hand-assisted technique is used, the cap of
the Gelport device can simply be replaced. The left colon and splenic exure are
then fully mobilized to ensure a tension-free anastomosis. We nd that mobilization
of the splenic exure by starting at the inferior mesenteric vein (IMV) is very helpful (Fig.21.8). Creating a plane between the mesocolon and the retroperitoneum
underneath the IMV allows access to a “virginal plane” that has been undisturbed
by the previous peritonitis.
A colorectal anastomosis is then performed in the typical fashion. An air leak test
can be performed by using a laparoscopic suction irrigator to submerge the anastomosis while occluding the proximal colon with an atraumatic grasper.
Pitfalls andTroubleshooting
The timing of Hartmann’s reversal is largely surgeon dependent, with most advocating for a delay of several months from the index operation. This allows for reduction
in the postoperative and/or postinfection inammation seen after emergency surgery. While patients may push for early colostomy reversal for convenience, allowing for some delay may provide for lessening of the degree of adhesions and
facilitate the reversal. Reversal is typically delayed by 2–3months, although this
may be delayed by 6months or more in cases of delayed wound closure, malnutrition, or other long-lasting sequelae of intra-abdominal sepsis.
Adhesions make minimally invasive Hartmann’s reversal technically challenging. Access to an experienced assistant can be invaluable during these difcult